A Case of Postpartum Takotsubo (Stress) Cardiomyopathy.

Takotsubo (stress) cardiomyopathy (TCM) is usually triggered by psychological and/or physical stress. Most often, it is seen in postmenopausal women. Cases of TCM related to pregnancy are rare. We present a unique case of a 35-year-old, two-day postpartum female who was diagnosed with TCM.

Two PerPLEXing Cases of Hashimoto's Encephalopathy Unresponsive to Steroid and Intravenous Immunoglobulin Therapy.

Hashimoto's encephalopathy is a nebulous entity over which much controversy exists. Often referred to as steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT), it describes a myriad of neurological sequelae that typically are observed to occur in patients with the presence of thyroid antibodies. We aim to raise clinical awareness of this seldom diagnosed entity as a potential etiology for altered mental status in patients who present with supporting clinical features and elevated thyroid antibodies. While steroid responsiveness is deemed a typical presenting feature of this medical condition, our cases aim to describe two cases that required escalation of therapy to intravenous immunoglobulins, and ultimately, plasmapheresis therapy for improvement in their clinical status. Our patients had a dramatic improvement in their mentation within three to four sessions of plasmapheresis, improving rapidly toward their baseline. Such a dramatic improvement, coupled with the corresponding reduction in their thyroid antibody titer supports the diagnosis of Hashimoto's encephalopathy and highlights the importance of having a low clinical threshold for the diagnosis of this entity in patients who, despite extensive evaluation, reveal no apparent cause for their altered mental status.

Blasting Into Acute Coronary Syndrome.

Acute coronary syndrome (ACS) is a condition that develops from reduced blood flow and oxygen delivery through the coronary arteries which leads to cardiac ischemia. In the case presented here, the patient's ACS was precipitated by his underlying condition of chronic myelogenous leukemia (CML). Several complications can arise in patients with CML, one of them being blast crisis. Blast crisis is defined by 20% or greater blasts in the peripheral blood, or extramedullary proliferation of blasts. There is a known phenomenon of blood hyperviscosity that can develop in such patients which can lead to complications of stroke-like symptoms, congestive heart failure, and acute respiratory failure. In such cases, leukostasis rarely leads to myocardial ischemia. We present a challenging case of a patient with an acute coronary syndrome (ACS) precipitated by a blast crisis. This case highlights a potentially life-threatening cardiac complication of CML in patients with coronary artery disease and aimed to provide an optimal treatment strategy to improve outcomes.

Cardiac amyloid presenting as cardiogenic shock: case series.

BACKGROUND: Amyloidosis is a systemic infiltrative disease that can affect nearly every organ in the human body. It is characterized by the deposition of misfolded protein within various tissues and organs. Once there is cardiac involvement this portends a worse prognosis. CASE SUMMARY: We describe a case series of two patients with cardiac amyloidosis presenting as a cardiogenic shock. There were several missed opportunities in diagnosing cardiac amyloid prior to their fatal presentations. In the first case, a 65-year-old African-American male patient presented with worsening shortness of breath and signs of heart failure. Echocardiography revealed preserved ejection fraction. He was diagnosed with light chain subtype of cardiac amyloidosis, and rapidly deteriorated during his admission. Patient in the second case is a 75-year-old African-American female who presented with worsening heart failure and hypotension. Echocardiography revealed reduced ejection fraction. She was diagnosed with transthyretin cardiac amyloid. Her clinical status worsened during admission and she went into cardiogenic shock requiring multiple vasopressors. DISCUSSION: This case series discusses two incidences of cardiac amyloidosis presenting as cardiogenic shock in African-American patients. This article postulates that cardiac amyloidosis may be misdiagnosed for more common causes of heart failure especially among this demographic group. Once patients with cardiac amyloid present with cardiogenic shock their clinical course is typically rapidly fatal despite aggressive measures. Earlier detection is imperative to prevent poor outcomes.

Case of Coronavirus Disease 2019 Myocarditis Managed With Biventricular Impella Support.

Severe acute respiratory syndrome coronavirus 2, responsible for coronavirus disease 2019 (COVID-19), is a pandemic that has taken the world by storm. We present the only contemporary reported case of COVID-19 myocarditis leading to recovery with utilization of biventricular Impella (Abiomed, Danvers, MA, USA) for temporary mechanical circulatory support. A 35-year-old female with systemic sclerosis who was found to have five days of generalized malaise associated with fevers and cough. She tested positive for COVID-19 via nasal polymerase chain reaction. Cardiac enzymes were found elevated on admission. Invasive hemodynamics assessment was significant for elevated right and left-sided filling pressures, along with calculated cardiac index of 1.3 L/min/m2. Decision was made to place right and left-sided ventricular support with percutaneous Impella for mechanical circulatory support. She was started on intravenous immunoglobulin for suspected COVID-19 myocarditis along with remdesivir and solumedrol. After two weeks of continuous temporary mechanical circulatory support, the patient's hemodynamics improved and she was discharged. Repeat echocardiogram demonstrated normalization of left ventricular function.

Two cases of spontaneous pneumomediastinum with pneumothorax in patients with COVID-19 associated pneumonia.

Coronavirus 2019 (COVID-19) is an infectious viral illness caused by severe acute respiratory syndrome virus coronavirus 2 (SARS-CoV-2). This disease mainly affects the lungs manifesting as acute lung injury, pneumonia, and acute respiratory distress syndrome. We describe two patients who developed concomitant spontaneous pneumothorax and pneumomediastinum in the setting of SARS-CoV-2 leading to acute hypoxic respiratory failure. This report adds to the increasing number of cases describing pulmonary complications of COVID-19 infection. Further studies are needed to ascertain the prognostic significance of these pulmonary complications in patients with SARS-CoV-2 infection.

Because I Got High: Marijuana Induced Pseudo-Wellen's Syndrome.

Wellen's syndrome is a pattern on ECG that signifies impending acute myocardial infarction (MI) of the proximal left anterior descending (LAD) artery. This same pattern can also be noted in several benign diseases that may mimic Wellen's syndrome. Here we discuss a 36-year-old patient with no cardiac risk factors who presented with typical angina shortly after smoking marijuana. Upon arrival to the ED, an electrocardiogram revealed new biphasic T wave inversions in the anterolateral leads and cardiac biomarkers were found to be elevated. The patient was taken for emergent coronary angiography which revealed widely patent coronary arteries. Soon after, the patient was diagnosed with Pseudo-Wellen's syndrome secondary to cannabis use. This case report highlights the importance of identifying causes that may resemble Wellen's syndrome, especially in young adults without risk factors for acute coronary syndrome (ACS). Recognizing these cases can help avoid further invasive diagnostic testing, along with the complications that may go along with it.

Heerfordt-Waldenström Syndrome Manifesting as Cardiac Sarcoidosis.

Sarcoidosis is a granulomatous disease histologically characterized by non-caseating granulomas. Although it usually affects the lungs, it can affect any organ system and present with a wide variety of symptoms. Heerfordt-Waldenström Syndrome, or uveoparotid fever, is a rare form of sarcoidosis that presents with a combination of fever, parotitis, facial paralysis, and uveitis. In this case report, we demonstrate a rare manifestation of sarcoidosis in a patient who presents with both the aforementioned syndrome and cardiac involvement. This case serves to highlight the importance of identifying the various clinical manifestations and management of systemic sarcoidosis.